Early administration of angiotensin converting enzyme inhibi | Figure 1

Early Administration of ACE Inhibitors in DMD/BMD

Early administration of angiotensin converting enzyme inhibitors (ACEI - Enalapril Maleate) may delay the progression of myocardial fibrosis in young men with Duchenne muscular dystrophy (DMD) or Becker muscular dystrophy (BMD), according to the results of a clinical trial. The Brazilian group of the University of São Paulo conducted a randomized study in two centers in which 76 male patients (mean age at start of study: 13.1 years) were recruited between June 2009 and June 2012. All patients performed magnetic resonance imaging at the start of the study and at two years of follow-up. According to the group the early onset of the treatment with convertase inhibitor, before the cardiovascular magnetic resonance reveals myocardial fibrosis, benefits the patients with DMD or BMD. The researchers believe that the data will have some impact on the therapeutic guidelines for DMD and BMD, indicating earlier initiation of treatment with angiotensin-converting enzyme inhibitors, different from current practice, in which the use of convertase inhibitors is only initiated when the left ventricular ejection fraction is below normal.

Transcranial Magnetic Stimulation for Epilepsy

Background
Epilepsy is a common neurological disorder that appears in various forms. Many individuals with epilepsy have satisfactory seizure control with the use of antiepileptic medications. Yet, nearly a third of people with epilepsy suffer from frequent and uncontrolled seizures despite the use of medication, or are unable to tolerate the side effects of those medications. Surgery is an option for some people with uncontrolled seizures, but it is invasive and not suitable for all individuals. As a result, there remains a substantial unmet need for safe, effective therapies for these harder-to-treat epilepsies.
Transcranial magnetic stimulation (TMS) is one of several newer treatments that can potentially offer people with epilepsy a safe and non-invasive alternative to surgery. Long used as a research tool to study brain function, TMS has also been studied as a possible treatment for a number of nervous system conditions, including epilepsy. This non-surgical and painless treatment uses induced magnetic currents to regulate brain function in order to reduce the tendency to have seizures.

Objective
We aimed in this review to evaluate the evidence for the use of repetitive transcranial magnetic stimulation (rTMS) in individuals with epilepsy compared with other available treatments in reducing seizure frequency, improving quality of life, reducing epileptiform discharges (abnormalities on brain electrographic testing that suggest underlying brain disturbance or seizure tendency), antiepileptic medication use, and side effects.

Methods
The latest search for trials was 2 June 2020. We assessed the evidence from eight randomized controlled trials (studies in which participants are assigned to one of two or more treatment groups using a random method) involving a total of 241 participants comparing rTMS to control treatments (sham treatment, antiepileptic medication, or low-frequency rTMS).

Results
Some of the included trials showed that rTMS reduces the number of seizures individuals had compared to before the therapy, but other trials did not show any significant differences in seizure frequency. Four trials showed a reduction in epileptiform discharges following rTMS treatment. One study measured changes in quality of life in seven participants; although not statistically analyzed they found that a greater proportion of study participants reported increased quality of life scores with active treatments compared to the sham treatment.

Certainty of the evidence
Overall, we judged the certainty of the evidence for the main outcome of reduction in seizure frequency to be low due to unclear information in the published papers about study design and the unclear presentation of results. One included study commented on quality of life, but involved only seven participants. The evidence is current to June 2020.

Review of Heart Complications in DMD and BMD

Review question
What are the effects of treatments used to prevent or treat heart complications in Duchenne muscular dystrophy (DMD), Becker muscular dystrophy (BMD), and X-linked dilated cardiomyopathy (XLDCM)?
Cochrane Review; five trials (205 participants).

Key results and certainty of the evidence
Early treatment with ACE inhibitors or angiotensin receptor blockers (ARBs) may help people with DMD. In boys with early heart involvement, the effect of ACE inhibitor and ARB may be equivalent; however, the evidence is very uncertain. Findings from non-randomized studies, some of which have been long term, have led to the use of these drugs in daily clinical practice. Very low-certainty evidence indicates that adding eplerenone might give additional benefit in DMD when early cardiomyopathy is detected. No clinically meaningful effect for growth hormone or idebenone was found in the studies examined, although the certainty of the evidence was also very low. The trials provided only low or very low-certainty evidence on side effects. Overall, the numbers of patients in each of these studies were small, and some studies had limitations that might have affected the results, so we are very uncertain about the results.